APPLICATION FOR ENVIRONMENTAL HEALTH SERVICES - NHC
FILE NO_______________
PLEASE PRINT
Name: _______________________________ Mailing Address: _________________________________City/State/Zip___________
Home Phone: __________________Business/Mobile Phone:________________ E-mail Address: _____________________________
Street Address for Site: ___________________________Zip: _________Subdivision: __________________ Lot/Section: _________
Directions to Property: _________________________________________________________________________________________
________________________________________________County Sewer:
(YES)
(NO)
Installation for:
Lot Size: _______________________
Residence: ________________
No. of Bedrooms: ________________
Industrial / Commercial ______ (Type) ___________
Private Well: (YES)
(NO)
Duplex: __________________
Public System Name: _____________
OFFICE USE ONLY:
YOUR
Mobile Home Replacement
Building Addition/Conversion
Swimming Pool (Private)
Well Abandonment
Well Permit (new / replacement)
Well Repair/Reconstruction
Water Sample (Bacteriological)
Water Sample (Inorganic)
Water Sample (Resample)
Developments.
Permit Revision
TO MAKE APPLICATION FOR ENVIRONMENTAL HEALTH SERVICES
YOU MUST SUBMIT A PLAT OR SITE PLAN DRAWN TO SCALE OF
PROPERTY WITH THIS APPLICATION.
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Please show the location of the residence or building, including
driveways, and any other improvements/additions (pools, decks, etc.)
Permits issued pursuant to this application shall not be
affected by change in ownership provided the site plan remains
unchanged.
Please submit storm water plans for Subdivisions and Commercial
________
Amount Received: $ __________ Receipt #: _______
Cash _____ Check # __________ Credit Card ______
Date of Application
Tax Parcel #______________
Industry of Business:
Number of Employees: ____
Number/Type of water using
fixtures: ________________
The undersigned person hereby agrees that he/she has read this application.
It is understood that any permit issued hereafter are subject to suspension
or revocation if the site plans or the intended use change or if the information
submitted on this application is falsified.
Owner / Agent
EHS075
8-2008
NEW HANOVER COUNTY ENVIRONMENTAL HEALTH SERVICES FEE SCHEDULE
Soil Evaluation
Sewage System Construction Authorization (Type I, II, III)
Sewage System Construction Authorization (Type IV, V, VI)
Sewage System Permit Revision
Sewage System Repair Permit
Existing System Inspection (Building addition or Private pool)
Existing System Inspection (Reuse Purposes)
Reissue or Revise Construction Authorization
Land Record Review
Re-inspection after failed inspection at initial visit
$281.00 *plus $100 each additional 500 gal/day
$280.00
$832.00 *plus $100 each additional 500 gal/day
$140.00
$ 50.00
$140.00
$140.00
$140.00
$100.00 plus $50 each additional hour
$ 70.00
Well Permit ( Including site evaluation & bacterial analysis)
Water Sample – Bacteriological
Water Sample – Bacteriological
Water Sample – Chemical
Re-inspection after failed inspection at initial visit
$350.00
$140.00
$ 70.00
$140.00
$ 70.00
Food Service Plan Review
Prototype Restaurant & Food Stands
Non-prototype / Independent Restaurants, Food Stands & Mobile Food Units
Renovations / Changes (dimension of food preparation area, seating capacity or addition to room)
NC DENR – Division of EH approval letter
$250.00
$250.00
Temporary Food Establishment Permit
$ 75.00
Seafood Market Permit
Seafood Vehicle Permit
$100.00
$ 50.00
Swimming Pool – Operation permit
Swimming Pool – Plan Review (new facility construction
Re-inspection after failed inspection at initial visit
$200.00 **
$250.00
$ 70.00
Tattoo Artist and/or Body Piercing Permit per location
Tattoo Artist and/or Body Piercing per location paid less than 30 days prior to or after permit expiration
Tattoo Artist and/or Body Piercing Secondary Permit @ alternate location
Temporary Tattoo Artist and/or Body Piercing Permit
$200.00
$300.00
$125.00 ***
$100.00 **** operate 2 weeks or less
*
**
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First 500 gal/day
Second & subsequent facility @ same address 25% reduction
Tattoo and/or Body Piercing Shop under same ownership
Permit to operate 2 weeks or less
EHS091
7-2013
NEW HANOVER COUNTY
HEALTH DEPARTMENT
Environmental Health Services
230 Government Center Dr., Suite 140
Wilmington, NC 28403
TELEPHONE (910) 798-6667 FAX (910) 798-7815
CHECKLIST FOR APPLICATION FOR REUSE OF EXISTING SEPTIC/WELL
(INCLUDES BUILDING ADDITIONS/CONVERSIONS, MOBILE HOME
REPLACEMENTS, SWIMMING POOLS)
____ New Hanover County Health Department (NHCHD) Environmental Health Services
(EHS) application form (blue), completely filled out and signed
____ Owner’s consent to filing of this application, in writing, if applicant is not owner
____ Survey or other legal map showing property dimensions, boundaries, and all easements
____ Site plan, drawn to scale, between 1 in. = 10 ft. and 1 in. = 60 ft., showing all existing and
proposed development. Include any existing septic systems and wells. Include all
plumbing connections to sewer.
____ The lot must be cleared to allow visibility and access by foot AND the property
boundaries must be flagged or staked (flags will be provided). Edge of easement(s) must
be marked in the field.
____ Proposed addition to the property must be flagged or staked (flags will be provided).
____ Septic tank exposed to the invert of the inlet and outlet of the tank (If not stamped, may
require verification of liquid volume of tank)
____ Well heads underground located and exposed
____ Provide documentation from nearest provider of public sewer and/or water that
connection is not mandated. Without this, EHS cannot proceed with the processing of
the application.
I, _____________________________________________________(print name) certify that I
have fulfilled the above-referenced application requirements and the property is prepared for a
site visit.____________________________________________________________________
Signature of applicant/owner
EHS101
12-2015
“Healthy People, Safe Environment, Strong Community”
NOTICE TO APPLICANTS
FOR
ENVIRONMENTAL HEALTH SERVICES
ONSITE WASTEWATER PERMITS
PURSUANT TO 15A NCAC 18A .1937(d),
APPLICANTS SHALL PROVIDE WRITTEN PERMISSION AND
SIGNATURE OF PROPERTY OWNER AUTHORIZING APPLICANT
AS LEGAL REPRESENTATIVE IN THE APPLICATION PROCESS IF
APPLICANT IS NOT CURRENTLY THE OWNER OF RECORD OF
THE SUBJECT PROPERTY.
“Healthy People, Safe Environment, Strong Community”